Patient Noncompliance & Difficult Behavior: A Costly Mistake for Doctors

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Failure to Properly Manage Patient Noncompliance and Difficult Behavior Proves Costly Case Details The patient was a 76-year-old male with uncontrolled hypertension and a complex medical and surgical history, including cardiovascular disease with myocardial infarction, hypertension, elevated cholesterol levels, diabetes, gastroesophageal reflux disease, stent procedures, and colon resection. The patient had been seeing Dr. Green, a MedPro-insured family medicine physician, since 2008, and the doctor was aware of the patient's complex history. He was also cognizant of a variety of behavioral issues associated with the patient, including noncompliance with treatment plans, appointment cancellations and "no shows," and rude and demeaning behavior toward Dr. Green's office staff. Although Dr. Green noted these behaviors in the patient's record, his documentation was sparse and often illegible. During his tenure with Dr. Green, the patient was prescribed a variety of medications, including metoprolol, benazepril, aspirin, pioglitazone, and atorvastatin. In 2009, Dr. Green discontinued the atorvastatin, one year after prescribing it, due to the patient's complaints of chest pain and symptoms that Dr. Green thought were the result of myositis. No other cholesterol medications were prescribed after that point, despite the fact that the patient continued to experience elevated cholesterol levels. Additionally, Dr. Green recommended that the patient see his cardiologist to further investigate the symptom of chest pain. However, the patient did not follow through on that referral, and Dr. Green did not communicate with the cardiologist or follow up with the patient. In the spring of 2011, during a visit with Dr. Green, the patient's blood pressure was 193/81 mmHg. Dr. Green added amlodipine to the patient's medication regimen. At a 3-week follow-up visit, the patient's blood pressure was 151/85 mmHg. Three months later, at a follow-up visit, the patient's blood pressure was 159/80 mmHg.

Two months after that, the patient's blood pressure had increased to 173/90 mmHg. When asked whether he was taking the amlodipine as prescribed, the patient complained about the number of medications he was taking and what he described as a conspiracy by doctors and pharmaceutical companies to rip off the elderly. He also admitted that although he took the blood pressure medication, he did not take it every day and did not feel the need to do so. Dr. Green reinforced to the patient the necessity of following his treatment plan and the possible consequences of not taking his medications as prescribed. However, the doctor did not document this conversation, or the patient's defiant behavior, in the medical record. Less than 2 weeks after that follow-up visit, the patient died in this sleep. The patient's estate filed a malpractice suit against Dr. Green. The plaintiff's counsel speculated that the patient's death was due to a thromboembolic event and alleged that Dr. Green failed to properly treat the patient's hypertension and hyperlipidemia. The lawsuit also alleged that Dr. Green failed to educate and counsel the patient about lifestyle changes. Dr. Green agreed to settle the case before it went to trial. Risk Management Issues for This Claim

• Patient noncompliance with the treatment regimen

• Improper selection and management of an appropriate medication regimen

• Failure to obtain a cardiology consul

• Inadequate documentation related to patient noncompliance, difficult behavior, and patient education